Department of Vascular and Thoracic Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.
J Thorac Cardiovasc Surg. 2011 Nov;142(5):1032-7. doi: 10.1016/j.jtcvs.2010.11.051. Epub 2011 Mar 12.
The study objective was to compare the outcome between open and endovascular repair of acute traumatic rupture of the thoracic aorta.
Seventy-five patients (mean age 38.6 ± 10.7 years) with an acute traumatic aortic rupture were referred to the Arnaud de Villeneuve Hospital between January 1990 and January 2010. Between January 1990 and December 2000, 35 patients (33 men, mean age 35.8 ± 11.3 years) underwent surgical repair using cardiopulmonary bypass. From January 2001, an endovascular approach was deliberately chosen; 40 patients (30 male, mean age 41 ± 10.1 years) underwent endovascular repair. The 2 groups were statistically comparable.
The overall mortality rates for the surgical and endovascular groups were 11.4% (intraoperative mortality: 8.5%) and 2.5% (intraoperative mortality: 0%), respectively. The mortality rates related to aortic repair for the surgical and endovascular groups were 11.4% and 0%, respectively. In the surgical group, the morbidity rate was 14.2%: 4 cases of recurrent nerve palsy and 1 case of false anastomotic aneurysm were diagnosed at 52 months. In the endovascular group, the morbidity rate was 20%: 3 cases of intraoperative inadvertent coverage of supra-aortic trunks (requiring a secondary procedure in 2 cases after 1 and 2 years to revascularize the supra-aortic trunks), 1 proximal type I endoleak (requiring deployment of a second stent-graft at day 2), 2 stent-graft collapses in the first postoperative month (treated by open repair and explantation in 1 case and by the deployment of a second stent-graft in 1 case), 1 vertebrobasilar insufficiency after left subclavian artery coverage, and 1 intraoperative iliac rupture (surgically repaired). No cases of paraplegia or stroke were observed. The median follow-up was 7.7 (range, 0.4-15) years.
Compared with open repair, endovascular repair of traumatic thoracic aortic rupture is associated with a lower death rate but failed to reach statistical significance, most likely because of underpowering. These results prompt us to consider endovascular repair as the first-line therapy for acute traumatic rupture of the thoracic aorta, except in some rare but challenging anatomic situations. New stent-graft designs, sizes, and deployment systems could improve the results of endovascular repair in these indications.
本研究旨在比较开放性和血管内修复急性创伤性胸主动脉破裂的效果。
1990 年 1 月至 2010 年 1 月期间，共有 75 名（平均年龄 38.6 ± 10.7 岁）急性创伤性主动脉破裂患者被转诊至阿尔努夫·德维利讷夫医院。1990 年 1 月至 2000 年 12 月期间，35 名患者（33 名男性，平均年龄 35.8 ± 11.3 岁）接受了心肺旁路手术修复。自 2001 年 1 月起，我们选择了血管内治疗方法；40 名患者（30 名男性，平均年龄 41 ± 10.1 岁）接受了血管内修复。两组在统计学上具有可比性。
手术组和血管内组的总体死亡率分别为 11.4%（术中死亡率：8.5%）和 2.5%（术中死亡率：0%）。手术组和血管内组的主动脉修复相关死亡率分别为 11.4%和 0%。在手术组中，发病率为 14.2%：4 例膈神经麻痹和 1 例假吻合口动脉瘤，在 52 个月时诊断。在血管内组中，发病率为 20%：3 例术中意外覆盖主动脉弓分支（2 例在 1 年和 2 年后分别进行了二次手术以重新血运重建主动脉弓分支），1 例近端 I 型内漏（在第 2 天需要放置第二个支架移植物），2 例支架移植物在术后第一个月内塌陷（1 例通过开放修复和取出治疗，1 例通过放置第二个支架移植物治疗），1 例左锁骨下动脉覆盖后椎基底动脉供血不足，1 例术中髂动脉破裂（手术修复）。未观察到截瘫或中风病例。中位随访时间为 7.7 年（范围 0.4-15 年）。
与开放性修复相比，血管内修复创伤性胸主动脉破裂的死亡率较低，但未达到统计学意义，这很可能是由于效力不足。这些结果促使我们考虑将血管内修复作为急性创伤性胸主动脉破裂的一线治疗方法，除非在某些罕见但具有挑战性的解剖情况下。新的支架移植物设计、尺寸和部署系统可以改善这些适应证中血管内修复的结果。
